Medical Policy

1

Description

Lumbar spinal fusion (arthrodesis) is a surgical technique that involves fusion of 2 or more lumbar vertebrae using local bone, autologous bone taken from the iliac crest of the patient, allogeneic donor bone, or bone graft substitutes. There are numerous potential indications for lumbar spinal fusion. A number of these indications are controversial, for example when lumbar spinal fusion is performed in combination with discectomy for either herniated discs or degenerative disc disease, or in combination with decompression of the spinal canal for spinal stenosis when there is no suggestion of instability.

Related Policies

• Artificial Intervertebral Disc: Lumbar Spine

• Bone Morphogenetic Protein

• Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures

Policy

Lumbar spinal fusion may be considered medically necessary for any one of the following conditions:

• Spinal stenosis with both of the following:

o Any one of the following:

Associated spondylolisthesis demonstrated on plain x-rays

Spinal instability demonstrated on imaging studies

Spinal instability is anticipated due to need for bilateral or wide decompression with facetectomy or resection of pars interarticularis

o Either of the following:

Neurogenic claudication or radicular pain that results in significant functional impairment in a patient who has failed at least 3 months of conservative care and has documentation of central/lateral recess/or foraminal stenosis on MRI or other imaging

Severe or rapidly progressive symptoms of motor loss, neurogenic claudication, or cauda equina syndrome

• Severe, progressive idiopathic scoliosis with either of the following:

o Cobb angle greater than 40°

7.01.141 Lumbar Spinal Fusion Section 7.0 Surgery

Effective Date February 15, 2015

Subsection

Original Policy Date December 15, 2014

Next Review Date December 2015

Medical Policy

2

o Spinal cord compression with neurogenic claudication or radicular pain that results in significant functional impairment in a patient who has failed at least 3 months of conservative care

• Severe degenerative scoliosis (i.e., lumbar or thoracolumbar) with a minimum Cobb angle of 30°, or significant sagittal imbalance (e.g., sagittal vertical axis >5 cm), and with any one of the following:

o Documented progression of deformity with persistent axial (nonradiating) pain and impairment or loss of function unresponsive to at least 1 year of conservative therapy

o Persistent and significant neurogenic symptoms (claudication or radicular pain) with impairment or loss of function, unresponsive to at least 1 year of conservative nonsurgical care

o Severe or rapidly progressive symptoms of motor loss, neurogenic claudication or cauda equina syndrome

• Isthmic spondylolisthesis, when all of the following are present:

o Congenital (Wiltse type I) or acquired pars defect (Wiltse II), documented on x-ray

o Persistent back pain (with or without neurogenic symptoms), with impairment or loss of function

o Either unresponsive to at least 3 months of conservative nonsurgical care or with severe or rapidly progressive symptoms of motor loss, neurogenic claudication, or cauda equina syndrome

• Recurrent, same level, disc herniation, at least 3 months after previous disc surgery, when all of the following are present:

o Recurrent neurogenic symptoms (radicular pain or claudication) or evidence of nerve-root irritation, as demonstrated by a positive nerve-root tension sign or positive femoral tension sign or a corresponding neurologic deficit

o Impairment or loss of function

o Unresponsive to at least 3 months of conservative nonsurgical care or with severe or rapidly progressive symptoms of motor loss, neurogenic claudication, or cauda equina syndrome

o Neural structure compression and instability documented by imaging at a level and side corresponding to the clinical symptoms

• Pseudarthrosis, documented radiologically, when all of the following are present:

o No less than 6 months after initial fusion

o With persistent axial back pain, with or without neurogenic symptoms, or with severe or rapidly progressive symptoms of motor loss, neurogenic claudication, or cauda equina syndrome

o Impairment or loss of function, in a patient who had experienced significant interval relief of prior symptoms

Medical Policy

3

• Instability due to fracture, dislocation, infection, abscess, or tumor when extensive surgery is required that could create an unstable spine

• Iatrogenic or degenerative flatback syndrome with significant sagittal imbalance; when fusion is performed with spinal osteotomy or interbody spacers

• Adjacent level disease when all of the following are present:

o Persistent back pain (with or without neurogenic symptoms) with impairment or loss of function that is unresponsive to at least 3 months of conservative therapy

o Eccentric disc space collapse, spondylolisthesis, acute single level scoliosis, or lateral listhesis on imaging

o Symptoms and functional measures correlate with imaging findings

o The previous fusion resulted in significant relief for at least 6 months

Lumbar spinal fusion is considered investigational if the sole indication is any one of the following conditions:

• Disc herniation

• Chronic nonspecific low back pain without radiculopathy

• Degenerative disc disease

• Initial discectomy/laminectomy for neural structure decompression

• Facet syndrome

Lumbar spinal fusion is considered not medically necessary for any indication not addressed above.

Multiple level lumbar spinal fusion is considered not medically necessary when the criteria listed above are not met for all levels.

Policy Guidelines

Smoking within the previous 3 months is a contraindication for lumbar spinal fusion.

Conservative nonsurgical therapy for the duration specified should include all of the following:

• Use of prescription strength analgesics for several weeks at a dose sufficient to induce a therapeutic response

o Analgesics should include anti-inflammatory medications with or without adjunctive medications such as nerve membrane stabilizers or muscle relaxants

• Participation in at least 6 weeks of physical therapy (including active exercise) or documentation of why the patient could not tolerate physical therapy

• Evaluation and appropriate management of associated cognitive, behavioral, or addiction issues

• Documentation of patient compliance with the preceding criteria

Medical Policy

4

“Severely restricted functional ability” should generally include loss of function and/or documentation of inability or significantly decreased ability to perform normal daily activities of work, school or at-home duties.

Persistent debilitating pain is defined as:

• Significant level of pain on a daily basis defined on a visual analog scale (VAS) as greater than 4; AND

• Pain on a daily basis that has a documented impact on activities of daily living in spite of optimal conservative nonsurgical therapy as outlined above and appropriate for the patient.

Benefit Application

Benefit determinations should be based in all cases on the applicable contract language. To the extent there are any conflicts between these guidelines and the contract language, the contract language will control. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Some state or federal mandates (e.g., Federal Employee Program (FEP)) prohibit Plans from denying Food and Drug Administration (FDA) - approved technologies as investigational. In these instances, plans may have to consider the coverage eligibility of FDA-approved technologies on the basis of medical necessity alone.

Rationale

Background

Fusion of the lumbar spine can be approached from an anterior, lateral, or posterior direction. Anterior or posterior lumbar interbody fusion (ALIF/PLIF) are traditionally performed with an open approach (long incision with wide retraction of the musculature), but can also be performed through minimally invasive/minimal access procedures. Minimally invasive approaches that use specialized retractors include lateral transpsoas interbody fusion/lateral interbody fusion (e.g., LTIF, XLIF, DLIF), and transforaminal interbody fusion (TLIF). Posterolateral fusion (PLF) fuses the transverse processes alone and should be differentiated from the interbody procedures (e.g., PLIF) just described. Interbody cages, instrumentation such as plates, pedicle screws, or rods, and osteoinductive agents such as recombinant human bone morphogenetic protein (rhBMP) may be used to stabilize the spine during the months that fusion is taking place and to improve fusion success rates.

The objective of interbody fusion is to permanently immobilize the functional spinal unit (2 adjacent vertebrae and the disc between them) that is believed to be causing pain and/or neurologic impingement. An alternative or supplemental approach is fusion of the transverse processes. Lumbar fusion is most commonly accepted when it is used to stabilize an unstable spine or to correct deformity. For example, lumbar spondylolisthesis is an acquired anterior displacement (slip) of 1 vertebra over the subjacent vertebra that is associated with degenerative changes. Patients who do not have neurologic deficits will typically do well with conservative care. However, patients who present with sensory changes, muscle weakness or cauda equina syndrome are more likely to develop

Medical Policy

5

progressive functional decline without surgery. Scoliosis, an abnormal lateral and rotational curvature of the vertebral column, can result in severe deformity that is associated with back pain in adulthood and may lead to compromised respiratory function if it is not corrected. Scoliosis with severe deformity is also an accepted indication for spinal fusion.

Lumbar spinal fusion is more controversial when the conditions described previously are not present. For example, fusion is frequently performed in combination with discectomy or laminectomy when these procedures do not result in instability of the spine. Fusion has also been performed for degenerative disc disease. Degenerative disc disease is a universal age-related condition consisting of morphologic changes in the lumbar motion segment. As many degenerative changes seen on imaging are asymptomatic, and invasive provocative discography has variable accuracy in the ability to localize the pain generator, identifying the source of low back pain can be difficult. A large number of fusion operations are also performed for nonspecific low back pain that is not responsive to nonsurgical measures (e.g., nonsteroidal anti-inflammatory drugs, analgesics, physical therapy), when definite indications for fusion are not present. Across the U.S., there is wide variation in the rates of lumbar spinal fusion, and many experts consider lumbar fusion to be overused, indicating a need for better standardization and uniformity in the application of this procedure.

Regulatory Status

Lumbar spinal fusion is a surgical procedure and does not require approval by the U.S. Food and Drug Administration (FDA). A variety of instrumentation used in lumbar spinal fusion is cleared for marketing by FDA. Infuse (rhBMP-2) and OP-1 (rhBMP-7) are approved by FDA for specified indications (see Blue Shield of California Medical Policy: Bone Morphogenetic Protein).

Literature Review

Spinal Stenosis with Spondylolisthesis

A consensus statement from the North American Spine Society (NASS) defines degenerative lumbar spinal stenosis as a condition in which there is diminished space available for the neural and vascular elements in the lumbar spine secondary to degenerative changes in the spinal canal.(1) When symptomatic, this causes a variable clinical syndrome of gluteal and/or lower extremity pain and/or muscle fatigue which may occur with or without back pain.

NASS defines lumbar degenerative spondylolisthesis as an acquired anterior displacement of 1 vertebra over the subjacent vertebra, associated with degenerative changes, but without an associated disruption or defect in the vertebral ring.(2) Most patients with symptomatic degenerative lumbar spondylolisthesis and an absence of neurologic deficits do well with conservative care. Patients who present with sensory changes, muscle weakness, or cauda equina syndrome are more likely to develop progressive functional decline without surgery.

Weinstein et al reported findings from the multicenter controlled trial (Spine Patient Outcomes Research Trial [SPORT]) that compared surgical and nonsurgical treatment for lumbar degenerative spondylolisthesis.(3,4) All patients had neurogenic claudication or radicular leg pain associated with neurologic signs, spinal stenosis shown on cross-sectional imaging, and degenerative spondylolisthesis shown on lateral radiographs with symptoms persisting for at least 12 weeks. There were 304 patients in a randomized cohort and 303 patients in an observational cohort. About 40% of the randomized cohort

Medical Policy

6

crossed over in each direction by 2 years of follow-up. At the 4-year follow-up timepoint, 54% of patients randomized to nonoperative care had undergone surgery. Five percent of the surgically-treated patients received decompression only and 95% underwent decompression with fusion. Analysis by treatment-received was used due to the high percentage of crossovers. This analysis, controlled for baseline factors, showed a significant advantage for surgery at up to 4 years of follow-up for all primary and secondary outcome measures.

A 1991 study by Herkowitz et al evaluated decompression, with or without fusion, in 50 patients with spondylolisthesis and spinal stenosis.(5) All patients had failed a trial of nonoperative treatment. This quasirandomized prospective study used alternating assignment to the 2 treatment groups. At a mean follow-up of 3 years (range, 2.4-4.0), the patients who had posterolateral lumbar fusion together with decompression had significantly improved outcomes, as measured by overall outcomes and numeric rating scales, compared with the group of patients who underwent decompression alone.

Section Summary

Findings from the SPORT trial, in which 95% of patients in the surgical group underwent decompression with fusion and the smaller study by Herkowitz et al that specifically assessed the addition of fusion to decompression, support that the use of lumbar spinal fusion improves outcomes in patients with spinal stenosis associated with spondylolisthesis.

Adolescent Idiopathic Scoliosis

Scoliosis is an abnormal lateral and rotational curvature of the vertebral column. Treatment of scoliosis currently depends on 3 factors: the cause of the condition (idiopathic, congenital, secondary), severity of the condition (degrees of curve), and the remaining growth expected for the patient at the time of presentation. Children who have vertebral curves measuring between 25° and 40° with at least 2 years of growth remaining are considered to be at high risk of curve progression. Because severe deformity may lead to compromised respiratory function and is associated with back pain in adulthood, in the U.S., surgical intervention with spinal fusion is typically recommended for curves that progress to 45° or more.(6)

In 2001, Danielsson and Nachemson reported long-term follow-up on 283 consecutive patients who had been treated with a brace or with surgical treatment for adolescent idiopathic scoliosis in Sweden.(7) Lumbar curves of less than 60° were treated with a brace worn for an average of 2.7 years. Curves of 60° or more were treated with fusion using bone grafts from the iliac crest. An average of 9.5 vertebrae were fused. Clinical and radiologic follow-up was obtained in 89% of patients at a mean of 22 years (range, 20-28). Curve progression was 3.5° for surgically-treated curves and 7.9° for brace-treated curves. Five patients (4%) treated surgically and 39 (36%) treated with bracing had an increase in the Cobb angle of more than 10°.

Section Summary

Long-term follow-up of a large case series supports guidelines from the Scoliosis Research Society that fusion can reduce curve progression in patients with curves greater than 40°. This is likely to result in reduced morbidity for treated patients.

Adult Symptomatic Lumbar Scoliosis

In 2009, Bridwell et al reported a prospective multicenter cohort study that compared operative versus nonoperative treatment of adult symptomatic lumbar scoliosis (defined

Medical Policy

7

as a minimum Cobb angle of 30°) in 160 consecutively enrolled patients.(8) Operative versus nonoperative treatment was decided by the patient and medical team. Nonoperative treatment included observation (21%), medications (26%), medications plus physical therapy and/or injections (40%), and other treatment without medications (13%). For analysis, the patients were matched using propensity scores that included baseline Cobb angle, Oswestry Disability Index (ODI), Scoliosis Research Society subscore, and a numerical rating scale for back and leg pain. The percentage of patients who returned for follow-up at 2 years was higher for operative than nonoperative patients (95% vs 45%), though the baseline measures for patients who were lost to follow-up was similar to those who were followed for 2 years. At the 2-year follow-up, nonoperative treatment had not improved quality of life or any other outcome measures, while the operative group showed significant improvement in all outcomes.

Section Summary

No randomized controlled trials (RCTs) were identified on the treatment of adult symptomatic lumbar scoliosis with fusion. A cohort study, which may be subject to selection bias from the patient choice of treatment, reported superior outcomes in patients treated with fusion compared with nonoperative controls.

Isthmic Spondylolisthesis

In 2000, Moller and Hedlund reported a study of 111 patients with adult isthmic spondylolisthesis who were randomly assigned to posterolateral fusion (with or without instrumentation, n=77) or to an exercise program (n=34).(9) Inclusion criteria for the study were lumbar isthmic spondylolisthesis of any grade, at least 1 year of low back pain or sciatica, and a severely restricted functional ability. The mean age of patients was 39 years, with a mean age at onset of symptoms of 26 years. At 1- and 2-year follow-up, functional outcome (assessed by the Disability Rating Index) had improved in the surgery group but not in the exercise group. Pain scores improved in both groups, but were significantly better in the surgically treated group compared with the exercise group.

Section Summary

One RCT was identified that compared fusion versus an exercise program for patients with symptomatic isthmic spondylolisthesis. Results of this trial support that the use of fusion for this condition improves functional status compared with conservative treatment.

Spinal Fracture

A 2006 qualitative systematic review compared operative and nonoperative treatment for thoracolumbar burst fractures in patients without neurologic deficit.(10) Two RCTs were identified, one by Wood et al in 2003 (described next) and a second small study by Alany et al with 20 patients.

The study by Wood et al randomized 53 consecutive patients with a stable burst fracture and no neurologic deficit or loss of structural integrity to fusion with instrumentation or to nonoperative treatment with application of a body cast or orthosis for approximately 16 weeks.(11) At an average follow-up of 44 months (24 month minimum) the patients completed assessments of pain and function. At follow-up, the 2 groups were similar in the average fracture kyphosis, canal compromise, and return to work. Patients treated nonoperatively reported less disability on the ODI and Short Form-36 physical function, lower pain scores, and had fewer complications.

Medical Policy

8

Section Summary

Results of this small randomized trial indicate that spinal fusion may be associated with worse outcomes compared with conservative care in patients with spinal fracture without instability or neural compression.

Lumbar Disc Herniation With Radiculopathy

Weinstein et al also reported on randomized (n=501) and observational (n=743) cohorts of patients from the SPORT trial with lumbar disc herniation and radiculopathy who received either discectomy or nonoperative care.(12,13) There was no mention of any patient undergoing fusion following discectomy. Specific inclusion criteria at enrollment were radicular pain (below the knee for lower lumbar herniations, into the anterior thigh for upper lumbar herniations) and evidence of nerve-root irritation with a positive nerve-root tension sign (straight leg raise–positive between 30° and 70° or positive femoral tension sign) or a corresponding neurologic deficit (asymmetrical depressed reflex, decreased sensation in a dermatomal distribution, weakness in a myotomal distribution). Additionally, all participants were surgical candidates who had undergone advanced vertebral imaging (97% magnetic resonance imaging [MRI], 3% computed tomography [CT]) showing disk herniation (protrusion, extrusion, sequestered fragment) at a level and side corresponding to the clinical symptoms. Patients with multiple herniations were included if only 1 of the herniations was considered symptomatic (i.e., if only 1 was planned to be operated on). Exclusion criteria included prior lumbar surgery, cauda equina syndrome, scoliosis greater than 15°, segmental instability (>10° angular motion or >4-mm translation), vertebral fractures, spine infection or tumor, inflammatory spondyloarthropathy, pregnancy, comorbid conditions contraindicating surgery, inability/unwillingness to have surgery within 6 months. In the randomized cohort, 50% of patients assigned to discectomy and 30% of patients assigned to nonoperative treatment received surgery in the first 3 months. Intention-to-treat analysis for the randomized cohort found a small advantage for patients assigned to discectomy with no significant differences between the 2 groups for the primary outcome measures. Analysis by treatment received found significant advantages for discectomy. In the observational cohort, the 528 patients who chose surgery had greater improvement in the primary outcome measures of bodily pain, physical function, and ODI compared with the 191 patients who received usual nonoperative care. All groups improved over time.

Section Summary

Current evidence, which includes a large RCT, supports that surgical treatment with discectomy improves outcomes for lumbar disc herniation with radiculopathy. However, there is no evidence to support that the addition of spinal fusion to discectomy improves outcomes in patients with the sole indication of lumbar disc herniation without instability.

Chronic Low Back Pain Without Radiculopathy

Nonspecific chronic low back pain (CLBP) is persistent low back pain that is not attributable to a recognizable, known specific pathology such as infection, tumor, osteoporosis, fracture, structural deformity (e.g., spondylolisthesis, scoliosis), inflammatory disorder, radiculitis, or cauda equine syndrome. Surgical interventions, including fusion and disc arthroplasty, have been applied with the belief that abnormal intersegmental movement or degenerative pathology may be the cause of CLBP.(14)

A systematic review from 2013 assessed the number of studies that had been published up until that time on surgical fusion for CLBP.(15) As of September 2012, 4 RCTs with a

Medical Policy

9

total of 981 patients had been published comparing surgical versus nonsurgical approaches to CLBP. In contrast, 33 RCTs with a total of 3790 patients had compared variations of surgical techniques.

Another systematic review from 2013 compared lumbar fusion versus conservative treatment in patients with CLBP.(16) Meta-analysis of 4 trials (described next) with a total of 666 patients reported a reduction in the ODI that was -2.91 in favor of lumbar fusion. However, this did not attain statistical significance or the minimal clinically significant difference in ODI of 10 points. There was evidence of publication bias that favored placebo. The review concluded that there is strong evidence that lumbar fusion does not lead to a clinically significant reduction in perceived disability compared with conservative treatment in patients with CLBP and degenerative spinal disease. The review also concluded that it is unlikely that further research on the subject would alter this conclusion.

In 2012, the Agency for Healthcare Research and Quality posted for public comment a draft of an updated technology assessment on spinal fusion for treating painful lumbar degenerated discs or joints.(17) As of September, 2014, AHRQ lists the report as in the final production phase.(18) The draft, which reviewed 4 of the studies described next, concluded that the evidence was minimally sufficient to conclude that fusion was associated with improved back pain and function at 2 years compared with physical therapy, but that the clinical significance of these findings was uncertain. This technology assessment is being finalized for publication. One of the studies that compared surgical versus nonsurgical treatment for CLBP was a 2001 multicenter trial by the Swedish Lumbar Spine Study Group.(19) In this study, 294 patients with CLBP for at least 2 years, sick leave or disability for at least 1 year (mean, 3 years), and radiologic evidence of disc degeneration, were randomized into 1 of 3 types of spinal fusion or to physical therapy supplemented by other nonsurgical treatment. Patients were excluded if they had specific radiologic findings such as spondylolisthesis, new or old fractures, infection, inflammatory process, or neoplasm. With intention-to-treat analysis, the surgical group showed a greater reduction in back pain (33% vs 7%), disability according to ODI (25% vs 6% reduction), Million visual analog score (VAS, 28% vs 8%), and General Function Score (GFS, 31% vs 4%). Significantly more surgical patients were back to work (36% vs 13%), and more reported their outcome as better or much better (63% vs 29%).

A 2005 trial from the English Spine Stabilisation Trial Group was a pragmatic multicenter randomized trial that compared spinal fusion with an intensive (approximately 75 hours) physical and cognitive-behavioral rehabilitation program.(20) Patients (n=349) who had back pain for at least 1 year and were considered candidates for surgical stabilization of the spine by the treating physician were randomized if the clinician and patient were uncertain which of the study treatment strategies were best. Radiologic findings were not part of the inclusion criteria. By the 2-year follow-up, 48 (28%) patients who were randomized to rehabilitation had undergone surgery. Results for 1 of the 2 primary outcome measures (ODI) showed a modest but significantly greater improvement (4.1 points) in the surgery group. There were no significant differences between the groups for the walking test or for any of the secondary outcome measures.

In 2010, Brox et al reported 4-year follow-up from 2 randomized trials that compared surgery versus cognitive intervention and exercises in 124 patients with disc degeneration.(21) One of the studies enrolled patients with CLBP and radiographic evidence of disc degeneration; the other enrolled patients with chronic back pain after previous surgery for disc herniation. The criteria for symptomatic degenerative disc

Medical Policy

10

disease were based on imaging without other diagnostic tests to identify the source of the CLBP. The combined 4-year follow-up rate was 92% in the surgical group and 86% in the nonsurgical group. In the nonsurgical group, 24% had undergone surgery by 4 years. In the surgical group, 15 (25%) had reoperation for persistent complaints or deterioration of the condition. In the intention-to-treat analysis, there was no significant difference between the groups in the ODI or in the percentage of patients who were on disability at 4 years. For the secondary outcomes, the only treatment effect identified was a reduction of fear-avoidance beliefs favoring cognitive intervention and exercises. Interpretation of this study is limited by the high percentage of crossovers from nonsurgical to surgical treatment.

A smaller trial that is frequently cited is a 2011 study by Ohtori et al.(22) In this study, patients with discogenic low back pain for at least 2 years (without radiculopathy) were selected following demonstration of disc degeneration at 1 level based on MRI, pain provocation on discography, and pain relief following intradiscal injection of anesthetic. Forty-six patients did not agree to undergo discography or intradiscal anesthetic injection, and 11 patients were excluded because of negative results. Most of the patients (70%) were categorized with a bulging disc and the remaining had evidence of disc degeneration on MRI. The 41 patients included in the study were divided into a walking and stretching group (over a period of 2 years, n=20), or discectomy and fusion (n=21). The approach was anterior lumbar interbody fusion (ALIF, n=15) or alternatively posterolateral fusion (PLF, n=6) if the anterior approach was technically difficult due to blood vessel anatomy. At 2 years of follow-up, there was improvement for all groups on the VAS, Japanese Orthopedic Association Score, and ODI. The 2 surgical groups scored significantly better compared with the minimal treatment group on all measures, with some advantage of ALIF over PLF. For example, VAS improved from 7.7 to 4.7 in the minimal treatment group, from 7.4 to 1.3 in the ALIF group, and from 6.5 to 3.5 in the PLF group. A limitation of this study is the minimal treatment provided to the control group.

Section Summary

The results of trials comparing fusion with nonsurgical management in this population are mixed. A meta-analysis of results from 4 RCTs found no clinically significant advantage of lumbar fusion over conservative therapy in patients with CLBP that is not attributable to a recognizable, known specific pathology such as, infection, tumor, osteoporosis, fracture, structural deformity (e.g., spondylolisthesis, scoliosis), inflammatory disorder, radiculitis, or cauda equine syndrome. The strongest benefits of surgery were reported in a study of patients who had been on sick leave or disability for more than 1 year, while no advantage of surgery was found when the patients or surgeon were unsure of whether surgery or conservative therapy would be the best treatment strategy. Interpretation of these studies is limited by the high percentage of patients who cross over to surgery, variances in the type of spinal fusion (e.g., posterolateral vs interbody), and uncertainty in establishing whether the source of CLBP is from degenerative disc disease.

Summary

Lumbar spinal fusion (arthrodesis) is a surgical technique that involves fusion of 2 or more lumbar vertebrae using local bone, autologous bone taken from the iliac crest of the patient, or allogeneic donor bone. The literature was examined on the use of fusion for the following indications:

• Spinal Stenosis with spinal instability. Findings from the SPORT trial, in which 95% of patients in the surgical group underwent decompression with fusion, and a smaller study that specifically assessed the addition of fusion to decompression,

Medical Policy

11

support that fusion in patients with spinal stenosis associated with spondylolisthesis improves outcomes and therefore may be considered medically necessary for this indication.

• Idiopathic Scoliosis. Long-term follow-up of a large case series and guidelines from the Scoliosis Research Society provide support that fusion can reduce curve progression in patients with curves greater than 40°. Therefore, lumbar spinal fusion may be considered medically necessary for this population.

• Degenerative Scoliosis. No randomized controlled trials were identified on the treatment of adult symptomatic lumbar scoliosis with fusion. A cohort study found superior outcomes in patients treated with fusion compared with nonoperative controls. Based on this evidence, clinical input, and the strong rationale for its efficacy, spinal fusion may be considered medically necessary for adults with degenerative scoliosis.

• Isthmic Spondylolisthesis. One RCT was identified that compared fusion versus an exercise program in patients with symptomatic isthmic spondylolisthesis. Results of this trial support that fusion may be considered medically necessary for this condition.

• Spinal Fracture. Results of 1 small randomized trial indicate that spinal fusion for patients with spinal fracture without instability or neural compression may result in worse outcomes than nonsurgical management, and therefore spinal fusion is considered not medically necessary for this indication.

• Herniated Discs. Current evidence, which includes the large randomized controlled SPORT trial, supports surgical treatment with discectomy for lumbar disc herniation. Evidence is insufficient to conclude that the addition of fusion to discectomy improves outcomes in patients with lumbar disc herniation without instability. As a result, lumbar spinal fusion is considered investigational for this indication.

• Nonspecific Chronic Low Back Pain. Meta-analysis of results from 4 RCTs found no clinically significant advantage of lumbar fusion over conservative therapy in patients with nonspecific chronic low back pain that is unresponsive to conservative management. While some trials have reported a benefit, others have not. Due to the uncertainty as to whether outcomes are improved, spinal fusion is considered investigational for this population.

Practice Guidelines and Position Statements

In 2014, the North American Spine Society (NASS) published coverage policy recommendations for lumbar fusion.(23) Specific criteria were described for infection, tumor, traumatic injuries, deformity (e.g. scoliosis), stenosis, disc herniations, synovial facet cysts, discogenic low back pain, and pseudoarthrosis. NASS describes situations where lumbar fusion would not be indicated as disc herniation in the absence of instability or spondylolisthesis; stenosis in the absence of instability, foraminal stenosis or spondylolisthesis; and discogenic low back pain that does not meet the recommended criteria.

The 2008 Guidelines from NASS addressed the diagnosis and treatment of degenerative lumbar spondylolisthesis.(2,24)

• NASS gave a grade B recommendation for surgical decompression with fusion for the treatment of patients with symptomatic spinal stenosis and degenerative

Medical Policy

12

lumbar spondylolisthesis to improve clinical outcomes compared with decompression alone, and a grade C recommendation for decompression and fusion as a means to provide satisfactory long-term results for the treatment of patients with symptomatic spinal stenosis and degenerative lumbar spondylolisthesis.

The 2011 Guidelines from NASS addressed multidisciplinary spine care for adults with a chief complaint of degenerative lumbar spinal stenosis.(1,25)

• The guidelines indicate that the nature of the pain and associated patient characteristics should be more typical of a diagnosis of spinal stenosis than herniated disc. The evidence review addressed whether the addition of lumbar fusion to surgical decompression improves surgical outcomes in the treatment of spinal stenosis compared with treatment by decompression alone. NASS gave a grade B recommendation (fair evidence) for decompression alone for patients with leg predominant symptoms without instability

The 2012 Guidelines from NASS addressed multidisciplinary spine care for the diagnosis and treatment of lumbar disc herniation with radiculopathy.(26,27)

• The guidelines indicate that there is insufficient evidence to make a recommendation for or against fusion for specific patient populations with lumbar disc herniation with radiculopathy whose symptoms warrant surgery. The best evidence available suggests that outcomes are equivalent in patients with radiculopathy due to lumbar disc herniation whether or not a fusion is performed. Grade of Recommendation: I (Insufficient Evidence)

The 2014 guidelines from the American Association of Neurological Surgeons (AANS) and Congress of Neurological Surgeons (CNS) addressed fusion procedures for the lumbar spine.(28) The 2014 guidelines state that there is no evidence that conflicts with the recommendations formulated in the 2005 guidelines for fusion procedures for the lumbar spine.

• One- or two-level degenerative disease without stenosis or spondylolisthesis (part 7): AANS/CNS recommends that lumbar fusion be performed for patients whose low-back pain is refractory to conservative treatment (physical therapy or other nonoperative measures) and is due to 1- or 2-level degenerative disc disease without stenosis or spondylolisthesis (Grade B, based on multiple Level II studies).(29) A Grade C recommendation was given that discoblock “(a procedure that involves injecting the disc with an anesthetic agent instead of a contrast agent in an effort to eliminate as opposed to reproducing a patient’s pain)” be considered as a diagnostic option during the evaluation of a patient presenting with chronic low-back pain (single Level II study), but that the potential for acceleration of the degenerative process be included in the discussion of potential risks (part 6).(30)

• Disc herniation and radiculopathy (part 8): Lumbar spinal fusion is not recommended as routine treatment following primary disc excision in patients with a herniated lumbar disc causing radiculopathy (Grade C, Level IV evidence). Lumbar spinal fusion is recommended as a potential option in patients with herniated discs who have evidence of significant chronic axial back pain, work as manual laborers, have severe degenerative changes, or have instability associated with radiculopathy caused by herniated lumbar discs (Grade C, Level IV evidence). Reoperative discectomy combined with fusion is recommended as a treatment option in patients with a recurrent disc herniations associated with

Medical Policy

13

lumbar instability, or chronic axial low-back pain (Grade C, Level III evidence).(31)

• Stenosis and spondylolisthesis (part 9): Surgical decompression and fusion is recommended as an effective treatment alternative for symptomatic stenosis associated with degenerative spondylolisthesis in patients who desire surgical treatment (Grade B, Level II evidence). There was insufficient evidence to recommend a standard fusion technique.(32)

• Stenosis without spondylolisthesis (part 10): Surgical decompression is recommended for patients with symptomatic neurogenic claudication due to lumbar stenosis without spondylolisthesis who elect to undergo surgical intervention (Grade B, Level II/III evidence). In the absence of deformity or instability, lumbar fusion is not recommended as it has not been shown to improve outcomes in patients with isolated stenosis (Grade C, Level IV evidence).(33)

• AANS/CNS also provided recommendations on:(28)

o Assessment of functional outcome following lumbar fusion (part 2)

o Assessment of economic outcome (part 3)

o Radiographic assessment of fusion status (part 4)

o Correlation between radiographic outcome and function (part 5)

o Interbody techniques for lumbar fusion (part 11)

o Pedicle screw fixation as an adjunct to posterolateral fusion (part 12)

o Injection therapies (part 13)

o Brace therapy (part 14)

o Electrophysiological monitoring (part 15)

o Bone growth extenders and substitutes (part 16)

o Bone growth stimulators (part 17)

A 2011 American College of Occupational and Environmental Medicine update of their guidelines on low back disorders state that for third lumbar discectomy on the same disc, spinal fusion at the time of discectomy as an option has a recommendation of inconclusive/insufficient evidence (I).34

A 2009 clinical practice guideline from the American Pain Society (APS) describes the following recommendations(35):

• In patients with nonradicular low back pain who do not respond to usual, noninterdisciplinary interventions, it is recommended that clinicians consider intensive interdisciplinary rehabilitation with a cognitive/behavioral emphasis” (strong recommendation, high-quality evidence)

• In patients with nonradicular low back pain, common degenerative spinal changes, and persistent and disabling symptoms, it is recommended that clinicians discuss risks and benefits of surgery as an option” (weak recommendation, moderate-quality evidence)

• It is recommended that shared decision making regarding surgery for nonspecific low back pain include a specific discussion about intensive interdisciplinary rehabilitation as a similarly effective option, the small to moderate average

Medical Policy

14

benefit from surgery versus noninterdisciplinary nonsurgical therapy, and the fact that the majority of such patients who undergo surgery do not experience an optimal outcome. This recommendation is based on evidence that fusion surgery is superior to nonsurgical therapy without interdisciplinary rehabilitation, but no more effective than intensive interdisciplinary rehabilitation.

• There is insufficient evidence to determine if laminectomy with fusion is more effective than laminectomy without fusion.

In 2009, the United Kingdom’s National Institute for Health and Clinical Excellence (NICE) provided clinical guidelines on early management of persistent nonspecific low back pain.(36)

• NICE recommends that practitioners consider referral for spinal fusion for people who have completed an optimal package of care that includes a combined physical and psychological treatment program and still have severe nonspecific low back pain for which they would consider surgery.

U.S. Preventive Services Task Force Recommendations

The U.S. Preventive Services Task Force (USPSTF) has not addressed lumbar fusion.

Medicare National Coverage

In 2006, the Medicare Evidence Development and Coverage Advisory Committee was convened to provide recommendations on the quality and strength of evidence for the benefits and risks of spinal fusion surgery for chronic low back pain from lumbar degenerative disc disease.(33) Included in the meeting materials was a technology assessment that was commissioned by the Agency for Healthcare Research and Quality to evaluate spinal fusion for treatment of degenerative disease affecting the lumbar spine.

References 1. North American Spine Society. Diagnosis and Treatment of Degenerative Lumbar

Spinal Stenosis 2011. Available online at: https://www.spine.org/Documents/ResearchClinicalCare/Guidelines/LumbarStenosis.pdf. Accessed August 22, 2014.

2. North American Spine Society. Diagnosis and Treatment of Degenerative Spondylolisthesis. 2007. Available online at: https://www.spine.org/Documents/ResearchClinicalCare/Guidelines/Spondylolisthesis.pdf. Accessed August 22, 2014.

3. Weinstein JN, Lurie JD, Tosteson TD et al. Surgical versus nonsurgical treatment for lumbar degenerative spondylolisthesis. N Engl J Med 2007; 356(22):2257-70.

4. Weinstein JN, Lurie JD, Tosteson TD et al. Surgical compared with nonoperative treatment for lumbar degenerative spondylolisthesis. four-year results in the Spine Patient Outcomes Research Trial (SPORT) randomized and observational cohorts. J Bone Joint Surg Am 2009; 91(6):1295-304.

5. Herkowitz HN, Kurz LT. Degenerative lumbar spondylolisthesis with spinal stenosis. A prospective study comparing decompression with decompression and intertransverse process arthrodesis. J Bone Joint Surg Am 1991; 73(6):802-8.

6. Richards BS, Bernstein RM, D'Amato CR et al. Standardization of criteria for adolescent idiopathic scoliosis brace studies: SRS Committee on Bracing and Nonoperative Management. Spine (Phila Pa 1976) 2005; 30(18):2068-75; discussion 76-7.

Medical Policy

15

7. Danielsson AJ, Nachemson AL. Radiologic findings and curve progression 22 years after treatment for adolescent idiopathic scoliosis: comparison of brace and surgical treatment with matching control group of straight individuals. Spine (Phila Pa 1976) 2001; 26(5):516-25.

8. Bridwell KH, Glassman S, Horton W et al. Does treatment (nonoperative and operative) improve the two-year quality of life in patients with adult symptomatic lumbar scoliosis: a prospective multicenter evidence-based medicine study. Spine (Phila Pa 1976) 2009; 34(20):2171-8.

9. Moller H, Hedlund R. Surgery versus conservative management in adult isthmic spondylolisthesis--a prospective randomized study: part 1. Spine (Phila Pa 1976) 2000; 25(13):1711-5.

10. Thomas KC, Bailey CS, Dvorak MF et al. Comparison of operative and nonoperative treatment for thoracolumbar burst fractures in patients without neurological deficit: a systematic review. J Neurosurg Spine 2006; 4(5):351-8.

11. Wood K, Buttermann G, Mehbod A et al. Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit. A prospective, randomized study. J Bone Joint Surg Am 2003; 85-A(5):773-81.

12. Weinstein JN, Tosteson TD, Lurie JD et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA 2006; 296(20):2441-50.

13. Weinstein JN, Lurie JD, Tosteson TD et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT) observational cohort. JAMA 2006; 296(20):2451-9.

14. Allen RT, Rihn JA, Glassman SD et al. An evidence-based approach to spine surgery. Am J Med Qual 2009; 24(6 Suppl):15S-24S.

15. Andrade NS, Flynn JP, Bartanusz V. Twenty-year perspective of randomized controlled trials for surgery of chronic nonspecific low back pain: citation bias and tangential knowledge. Spine J 2013.

16. Saltychev M, Eskola M, Laimi K. Lumbar fusion compared with conservative treatment in patients with chronic low back pain: a meta-analysis. Int J Rehabil Res 2013.

17. Agency for Healthcare Research and Quality. Spinal fusion for treating painful lumbar degenerated discs or joints. Draft key questions. 2012. Available online at: http://effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?pageaction=displaytopic&topicid=410. Accessed August 22, 2014.

18. Agency for Healthcare Research and Quality. Technology Assessments in Progress. 2014; http://www.ahrq.gov/research/findings/ta/index.html#taprogress. Accessed September 30, 2014.

19. Fritzell P, Hagg O, Wessberg P et al. 2001 Volvo Award Winner in Clinical Studies: Lumbar fusion versus nonsurgical treatment for chronic low back pain: a multicenter randomized controlled trial from the Swedish Lumbar Spine Study Group. Spine (Phila Pa 1976) 2001; 26(23):2521-32; discussion 32-4.

20. Fairbank J, Frost H, Wilson-MacDonald J et al. Randomised controlled trial to compare surgical stabilisation of the lumbar spine with an intensive rehabilitation programme for patients with chronic low back pain: the MRC spine stabilisation trial. BMJ 2005; 330(7502):1233.

21. Brox JI, Nygaard OP, Holm I et al. Four-year follow-up of surgical versus non-surgical therapy for chronic low back pain. Ann Rheum Dis 2010; 69(9):1643-8.

22. Ohtori S, Koshi T, Yamashita M et al. Surgical versus nonsurgical treatment of selected patients with discogenic low back pain: a small-sized randomized trial. Spine (Phila Pa 1976) 2011; 36(5):347-54.

Medical Policy

16

23. North American Spine Society. NASS coverage policy recommendations: Lumbar fusion. 2014. Available online at: https://www.spine.org/Pages/PolicyPractice/Coverage/CoverageRecommendations.aspx. Accessed August 22, 2014.

24. Watters WC, 3rd, Bono CM, Gilbert TJ et al. An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spondylolisthesis. Spine J 2009; 9(7):609-14.

25. Kreiner DS, Shaffer WO, Baisden JL et al. An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis (update). Spine J 2013; 13(7):734-43.

26. North American Spine Society. Diagnosis and Treatment of Lumbar Disc Herniation with Radiculopathy: Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care. 2012. Available online at: https://www.spine.org/Documents/ResearchClinicalCare/Guidelines/LumbarDiscHerniation.pdf. Accessed August 22, 2014.

27. Kreiner DS, Hwang SW, Easa JE et al. An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy. Spine J 2014; 14(1):180-91.

28. American Association of Neurological Surgeons (AANS). Guideline update for the performance of fusion procedures for degenerative disease of the spine. J Neurosurg Spine. Jul 2014; 21(1):1-139 http://thejns.org/toc/spi/21/1. Accessed September 4, 2014.

29. Eck JC, Sharan A, Ghogawala Z et al. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 7: lumbar fusion for intractable low-back pain without stenosis or spondylolisthesis. J Neurosurg Spine. Jul 2014; 21(1):42-47.

30. Eck JC, Sharan A, Resnick DK et al. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 6: discography for patient selection. J Neurosurg Spine. Jul 2014; 21(1):37-41.

31. Wang JC, Dailey AT, Mummaneni PV et al. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 8: lumbar fusion for disc herniation and radiculopathy. J Neurosurg Spine. Jul 2014; 21(1):48-53.

32. Resnick DK, Watters WC, 3rd, Sharan A et al. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 9: lumbar fusion for stenosis with spondylolisthesis. J Neurosurg Spine. Jul 2014; 21(1):54-61.

33. Resnick DK, Watters WC, 3rd, Mummaneni PV et al. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 10: lumbar fusion for stenosis without spondylolisthesis. J Neurosurg Spine. Jul 2014; 21(1):62-66.

34. American College of Occupational and Environmental Medicine (ACOEM). Low Back Disorders. 2011; http://www.guideline.gov/content.aspx?id=38438. Accessed September 2, 2014.

35. Chou R, Loeser JD, Owens DK et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine (Phila Pa 1976) 2009; 34(10):1066-77.

36. National Institute for Health and Clinical Excellence. CG88 - Low back pain 2009. Available online at:

Medical Policy

17

http://www.nice.org.uk/nicemedia/live/11887/44343/44343.pdf. Accessed August 22, 2014.

37. Centers for Medicare and Medicaid Services. Spinal Fusion for the Treatment of Low Back Pain Secondary to Lumbar Degenerative Disc Disease. 2006. Available online at: http://www.cms.gov/medicare-coverage-database/details/technology-assessments-details.aspx?TAId=41. Accessed August 22, 2014.

38. Blue Cross Blue Shield Association. Medical Policy Reference Manual, No. 7.01.141 (November 2014).

Appendix

Procedures used for lumbar interbody fusion differ primarily in the direction of approach to the spine (i.e., from the front [anterior], from the back [posterior or transforaminal] or from the side [lateral]). An alternative approach to interbody fusion is arthrodesis of the transverse processes alone (posterolateral), which does not fuse the adjoining vertebral bodies. Circumferential fusion fuses both the adjacent vertebral bodies and the transverse processes, typically using both an anterior and posterior approach to the spine.

Open and Minimally Invasive Approaches to Lumbar Interbody Fusion (LIF)

Procedure Access Approach Visualization Anterior (ALIF) Open, MI, or

laparoscopic Transperitoneal or retroperitoneal

Direct, endoscopic or laparoscopic with fluoroscopic guidance

Posterior (PLIF) Open or MI Incision centered over spine with laminectomy/laminotomy and retraction of nerve

Direct, endoscopic or microscopic, with fluoroscopic guidance

Transforaminal (TLIF)

Open or MI Offset from spine, through the intervertebral foramen via unilateral facetectomy

Direct, endoscopic or microscopic, with fluoroscopic guidance

Lateral Extreme lateral (XLIF) Direct lateral (DLIF)

MI Retroperitoneal through transpsoas

Direct, with neurologic monitoring and fluoroscopic guidance

Anterior Lumbar Interbody Fusion (ALIF)

Anterior access provides direct visualization of the disc space, potentially allowing a more complete discectomy and better fusion than lateral or posterior approaches. An anterior approach avoids trauma to the paraspinal musculature, epidural scarring, traction on nerve roots, and dural tears. However, the retraction of the great vessels, peritoneal contents, and superior hypogastric sympathetic plexus with a peritoneal or retroperitoneal approach place these structures at risk of iatrogenic injury. Access to the posterior space for the treatment of nerve compression is also limited. Laparoscopic ALIF has also been investigated.

Posterior Lumbar Interbody Fusion (PLIF)

PLIF can be performed through either a traditional open procedure with a midline incision or with a minimally invasive approach using bilateral paramedian incisions. In the open procedure, the midline muscle attachments are divided along the central incision to facilitate wide muscle retraction and laminectomy. In minimally invasive PLIF, tubular

Medical Policy

18

retractors may be used to open smaller central bilateral working channels to access the pedicles and foramen. Minimally invasive PLIF typically involves partial laminotomies and facetectomies. The decompression allows treatment of spinal canal pathology (e.g., spinal stenosis, lateral recess and foraminal stenosis, synovial cysts, hypertrophic ligamentum flavum), as well as stabilization of the spine through interbody fusion.

Transforaminal Lumbar Interbody Fusion (TLIF)

TLIF is differentiated from the more traditional bilateral PLIF by a unilateral approach to the disc space through the intervertebral foramen. In minimally invasive TLIF, a single incision about 2 to 3 cm in length is made approximately 3 cm lateral to the midline. A tubular retractor is docked on the facet joint complex and a facetectomy with partial laminectomy is performed. Less dural retraction is needed with access through the foramen via unilateral facetectomy, and contralateral scar formation is eliminated. TLIF provides access to the posterior elements along with the intervertebral disc space.

Lateral Interbody Fusion

Lateral interbody fusion (e.g., extreme lateral interbody fusion [XLIF] or direct lateral interbody fusion [DLIF])uses specialized retractors in a minimally invasive, lateral approach to the anterior spine through the psoas. In comparison with ALIF, the lateral approach does not risk injury to the peritoneum or great vessels. However, exposure to the spine may be more limited, and dissection of the psoas major places the nerves of the lumbar plexus at risk. Electromyographic monitoring and dissection predominantly within the anterior psoas major may be utilized to reduce the risk of nerve root injury. These various factors decrease the ability to perform a complete discectomy and address pathology of the posterior elements.

Circumferential Fusion

Circumferential fusion is 360° fusion that joins vertebrae by their entire bodies and transverse processes, typically through an anterior and posterior approach.

Posterolateral Fusion (PLF)

PLF is a procedure where the transverse processes of the involved segments are decorticated and covered with a mixture of bone autograft or allograft.

Documentation Required for Clinical Review

• History and physical and/or consultation notes including:

o Reason for procedure

o Clinical findings

o Conservative treatments and duration

o Activity limitations

o Duration of back pain

o Comorbidities

• Radiology report(s) (i.e., MRI, CT, discogram)

Post Service

• Procedure report(s)

Medical Policy

19

Coding

This Policy relates only to the services or supplies described herein. Benefits may vary according to benefit design; therefore, contract language should be reviewed before applying the terms of the Policy. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement.

MN/IE

The following service/procedure may be considered medically necessary in certain instances and investigational in others. Services may be medically necessary when policy criteria are met. Services are considered investigational when the policy criteria are not met or when the code describes application of a product in the position statement that is investigational.

Type Code Description

20930

Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure)

20931 Allograft, structural, for spine surgery only (List separately in addition to code for primary procedure)

20936

Autograft for spine surgery only (includes harvesting the graft); local (e.g., ribs, spinous process, or laminar fragments) obtained from same incision (List separately in addition to code for primary procedure)

20937

Autograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial incision) (List separately in addition to code for primary procedure)

20938

Autograft for spine surgery only (includes harvesting the graft); structural, bicortical or tricortical (through separate skin or fascial incision) (List separately in addition to code for primary procedure)

22532 Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic

22533 Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar

22534

Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic or lumbar, each additional vertebral segment (List separately in addition to code for primary procedure)

22556 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic

Medical Policy

20

22558 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar

22585

Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (List separately in addition to code for primary procedure)

22586

Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft when performed, L5-S1 interspace

22610 Arthrodesis, posterior or posterolateral technique, single level; thoracic (with lateral transverse technique, when performed)

22612 Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed)

22614

Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (List separately in addition to code for primary procedure)

22630

Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar

22632

Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; each additional interspace (List separately in addition to code for primary procedure)

22633

Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbar

22634

Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; each additional interspace and segment (List separately in addition to code for primary procedure)

22800 Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments

22802 Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to 12 vertebral segments

22804 Arthrodesis, posterior, for spinal deformity, with or

Medical Policy

21

without cast; 13 or more vertebral segments

22808 Arthrodesis, anterior, for spinal deformity, with or without cast; 2 to 3 vertebral segments

22810 Arthrodesis, anterior, for spinal deformity, with or without cast; 4 to 7 vertebral segments

22812 Arthrodesis, anterior, for spinal deformity, with or without cast; 8 or more vertebral segments

22818 Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and posterior elements); single or 2 segments

22819 Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and posterior elements); 3 or more segments

22830 Exploration of spinal fusion

22840

Posterior non-segmental instrumentation (e.g., Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary procedure)

22841 Internal spinal fixation by wiring of spinous processes (List separately in addition to code for primary procedure)

22842

Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments (List separately in addition to code for primary procedure)

22843

Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires); 7 to 12 vertebral segments (List separately in addition to code for primary procedure)

22844

Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires); 13 or more vertebral segments (List separately in addition to code for primary procedure)

22845 Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure)

22846 Anterior instrumentation; 4 to 7 vertebral segments (List separately in addition to code for primary procedure)

22847 Anterior instrumentation; 8 or more vertebral segments (List separately in addition to code for primary procedure)

22851

Application of intervertebral biomechanical device(s) (e.g., synthetic cage(s), methylmethacrylate) to vertebral defect or interspace (List separately in addition to code for primary procedure)

HCPC None

Medical Policy

22

ICD-9 Procedure

81.06 Lumbar and lumbosacral fusion of the anterior column, anterior technique

81.07 Lumbar and lumbosacral fusion of the posterior column, posterior technique

81.08 Lumbar and lumbosacral fusion of the anterior column, posterior technique

81.36 Refusion of lumbar and lumbosacral spine, anterior column, anterior technique

81.37 Refusion of lumbar and lumbosacral spine, posterior column, posterior technique

81.38 Refusion of lumbar and lumbosacral spine, anterior column, posterior technique

ICD-10 Procedure

For dates of service on or after 10/01/2015 0SG0070, 0SG0071, 0SG007J, 0SG00A0, 0SG00A1, 0SG00AJ, 0SG00J0, 0SG00J1, 0SG00JJ, 0SG00K0, 0SG00K1, 0SG00KJ, 0SG00Z0, 0SG00Z1, 0SG00ZJ, 0SG0370, 0SG0371, 0SG037J, 0SG03A0, 0SG03A1, 0SG03AJ, 0SG03J0, 0SG03J1, 0SG03JJ, 0SG03K0,0SG03K1, 0SG03KJ, 0SG03Z0, 0SG03Z1, 0SG03ZJ 0SG0470, 0SG0471, 0SG047J, 0SG04A0, 0SG04A1, 0SG04AJ, 0SG04J0, 0SG04J1, 0SG04JJ, 0SG04K0 0SG04K1, 0SG04KJ, 0SG04Z0, 0SG04Z1, 0SG04ZJ

Lumbar spinal fusion single joint, code list

0SG1070, 0SG1071, 0SG107J, 0SG10A0, 0SG10A1, 0SG10AJ, 0SG10J0, 0SG10J1, 0SG10JJ, 0SG10K0, 0SG10K1, 0SG10KJ, 0SG10Z0, 0SG10Z1, 0SG10ZJ, 0SG1370, 0SG1371, 0SG137J, 0SG13A0, 0SG13A1, 0SG13AJ, 0SG13J0, 0SG13J1, 0SG13JJ, 0SG13K0,0SG13K1, 0SG13KJ, 0SG13Z0,

Lumbar spinal fusion 2 or more joints, code list

Medical Policy

23

0SG13Z1, 0SG13ZJ 0SG1470, 0SG1471, 0SG147J, 0SG14A0, 0SG14A1, 0SG14AJ, 0SG14J0, 0SG14J1, 0SG14JJ, 0SG14K0 0SG14K1, 0SG14KJ, 0SG14Z0, 0SG14Z1, 0SG14ZJ

ICD-9 Diagnosis All Diagnoses

ICD-10 Diagnosis

For dates of service on or after 10/01/2015 All Diagnoses

IE

The following services are considered investigational and therefore not covered for any indication.

Type Code Description

CPT®

0195T

Arthrodesis, pre-sacral interbody technique, disc space preparation, discectomy, without instrumentation, with image guidance, includes bone graft when performed; L5-S1 interspace

0196T

Arthrodesis, pre-sacral interbody technique, disc space preparation, discectomy, without instrumentation, with image guidance, includes bone graft when performed; L4-L5 interspace (List separately in addition to code for primary procedure)

HCPC None ICD-9 Procedure None

ICD-10 Procedure

For dates of service on or after 10/01/2015 None

ICD-9 Diagnosis All Diagnoses

ICD-10 Diagnosis

For dates of service on or after 10/01/2015 All Diagnoses

Policy History

This section provides a chronological history of the activities, updates and changes that have occurred with this Medical Policy.

Effective Date Action Reason 3/5/2012 New policy Medical Policy Committee

Medical Policy

24

4/12/2012 Coding Update Administrative Review 5/8/2012 Administrative Update Administrative Review 5/18/2012 Coding Update Administrative Review 7/6/2012 Coding Update Administrative Review 2/22/2013 Coding Update Administrative Review 12/15/2014 Policy title change from Spinal

Fusion

Policy revision with position change effective 2/15/2015

Medical Policy Committee

2/15/2015 Policy revision with position change

Medical Policy Committee

Definitions of Decision Determinations

Medically Necessary: A treatment, procedure or drug is medically necessary only when it has been established as safe and effective for the particular symptoms or diagnosis, is not investigational or experimental, is not being provided primarily for the convenience of the patient or the provider, and is provided at the most appropriate level to treat the condition.

Investigational/Experimental: A treatment, procedure or drug is investigational when it has not been recognized as safe and effective for use in treating the particular condition in accordance with generally accepted professional medical standards. This includes services where approval by the federal or state governmental is required prior to use, but has not yet been granted.

Split Evaluation: Blue Shield of California / Blue Shield of California Life & Health Insurance Company (Blue Shield) policy review can result in a Split Evaluation, where a treatment, procedure or drug will be considered to be investigational for certain indications or conditions, but will be deemed safe and effective for other indications or conditions, and therefore potentially medically necessary in those instances. Prior Authorization Requirements

This service (or procedure) is considered medically necessary in certain instances and investigational in others (refer to policy for details).

For instances when the indication is medically necessary, clinical evidence is required to determine medical necessity.

For instances when the indication is investigational, you may submit additional information to the Prior Authorization Department.

Within five days before the actual date of service, the Provider MUST confirm with Blue Shield that the member's health plan coverage is still in effect. Blue Shield reserves the right to revoke an authorization prior to services being rendered based on cancellation of the member's eligibility. Final determination of benefits will be made after review of the claim for limitations or exclusions.

Questions regarding the applicability of this policy should also be directed to the Prior Authorization Department. Please call 1-800-541-6652 or visit the Provider Portal www.blueshieldca.com/provider.

Medical Policy

25

The materials provided to you are guidelines used by this plan to authorize, modify, or deny care for persons with similar illness or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract. These Policies are subject to change as new information becomes available.